2017 Sec 1 Green Book

A.

Bergevin

et

al.

/ International

Journal

of Pediatric Otorhinolaryngology

79

(2015)

2090–2093

following

Utah

legislature

in

February,

2013 three

[11] .

This

bill mandated

CMV their

audiological

evaluation,

only

the

cost

of

their

screening additional

of

newborns

under

weeks

of

age the

who first

fail

included

in

the

analysis.

Screening

costs

and

testing

is

hearing

screen(s).

Utah

became driven

state

to

costs

are

included

for

infants with

confirmed

hearing

newborn

treatment

loss 2 .

infant 3 .

this

targeted

hearing

loss

testing

approach

for

The

cost

of

the

screening

itself was

$66

per

implement

diagnosis when

the

bill was

signed

into

law

in

June

2013.

the costs

for

those children

likely

to

CMV

The analysis only considers

from

Utah’s

newborn

hearing

screening

program

show

on

public

insurance

because

we

are

using

a

governmental

Data

be

during

the

first

year

of

implementation

of

the

law

89%

of

We

estimated

the

proportion

of

publicly

insured

that

perspective.

the

two hearing

screens

and

that 63% of

the

using

a

range

of

values

and

varied

them

in

our

sensitivity

newborns underwent

infants analysis

assumptions 4 .

who

failed

the

two

newborn

hearing

screens

were

to

test

the

impact

of

our

children screened infants)

for CMV

( n = 244). Among

the

children

screened,

5%

(12

infants

with

confirmed

hearing

loss

will

incur

medical

All

tested

positive

for

CMV.

Some

of

these

CMV

positive

costs.

This

analysis

considers confirmed

the

added

costs CMV

to

the

treatment

found

to

have

normal

hearing

following

audiologic

per

patient

with

congenital

and

a

infants were evaluation. The

government

loss. Treatment of CMV-induced

diagnosis of sensorineural hearing

enormous

potential

health

burden

of

congenital

CMV

loss will

likely be

identical

to other

types of hearing

loss

in

hearing

that

it

is vital

that we assess

the benefits of early detection

for the prescription of antiviral medication and

tests

suggests relative

infants except

treatment 5 . The

to the potentially significant costs of early CMV

testing and

the patient during

cost data presented

to monitor

To

date,

only

one

such

cost

analysis

has

been

done

represent

the

cost

to

the

provider without

any markup

for

treatment.

here

the

authors

found

targeted

newborn

screening

in

the United

include $4453

for

the antiviral medication

for 6

and

profit margins and

to

be

cost

effective

[12] . Given

the

differences

in

health study states,

and

$385.63

for

testing. As insurance

such

they may underestimate

Kingdom insurance

months

in

the

United

Kingdom,

it

is

unclear States.

if

these other

costs

from

a

private

perspective

but may

overesti-

the

extrapolate

to

the

United

As

the

costs

from

a

Medicaid

reimbursement reimbursement

perspective.

findings would

mate

Illinois and Connecticut,

consider or have

the

ability

to

secure Medicaid

rates,

these

including Texas, Hawaii,

Absent

passed

similar

legislation,

there

is

a

need

to

perform

a

data were estimates. We present different hypothetical models our best

recently

cost

analysis

to

inform ex-ante to assess

public

policy

in

the United

States.

that

include avoiding

cost–benefit

analysis

uses

an

approach

and

a

governmental

implantation implantation

in

patients

treated with

antiviral

therapy.

This

cochlear Cochlear analysis.

the projected costs and benefits of

is

one

of

the

most

costly

factors

in

the for

accounting perspective

law.

Cochlear

implants

cost

$47,800

per

year

($95,600

the Utah

thus, avoiding

implants

bilateral) whereas hearing aids are $2000;

save

anywhere

from

$46,800

to

$93,600

per

patient include

[5] .

will

and methods

2. Materials

transparent

cost

benefit

analysis

must

several

A

of

the

analysis,

varying

the

assumptions

to

illustrate Because the first

iterations

Determining

costs &

benefits

2.1.

sensitive

the

results

are

to

particular

choices made.

how most

costs

related

to newborn hearing

loss are

incurred

in

fell

cleanly

into

two

categories:

administrative

costs

and the

Costs

year or this analysis as all costs andbenefits occurmore or less in the present.Manyof the costs and benefits that will accrue in the future are to individuals, families and educational institutions rather than to the government. In our estimation, the society-wide benefits of early detection and intervention far exceed those presented here. For the following models, all calculations project forward two years into the program. two of life, no discounting is necessary for

costs.

Administrative

costs

were

those

incurred

by

medical

of of

Health

for

both

the

education

and

screening

Department components

the

program.

The

government

also

bears

the

costs

for

those

affected

infants

covered

by

the

public

medical

(CHIP & Medicaid). Medical costs

include both

insurance programs

CMV

screening

test

and

the

differential

cost

of

treatment

for

the

infants.

Benefits were

narrowly

defined

as medical

CMV-positive

avoided

that would have

otherwise been

incurred had

there

costs

3. Results

early

screening

and

intervention. Benefits

to

individuals,

not been families,

and

private

insurers were

not

considered

and

cases

of

initial model

presented

in

Table

1

provides

a

baseline.

It

The

entirely

through

education

and prevention

efforts

CMV prevented

that

the

rate of public

insurance

coverage

for

infants will

assumes

in this analysis. The analysis thus provides a societal and even governmental benefits

were also not captured conservative estimate, as

2 Of

these

9

CMV

positive

children,

5

had

confirmed

hearing

loss

after

further

the

law

certainly

exceed what

is

captured

here.

from

these children are at

risk of developing more extensive hearing

loss

in to

testing. All of

childhood

as

CMV

induced

hearing

loss

is

progressive,

but we

are

unable

early

Quantifying

costs

and

benefits

2.2.

these more

distant

potential

costs

for

the

subgroup without

confirmed

consider hearing

loss

( n = 4)

due

to

lack

of

data.

3 Medical

costs were calculated using a multi-hospital

cost accounting database.

from

the

legislative fiscal note

Administrative costs were drawn

we’d

prefer

to

use

Medicaid/CHIP

cost

reimbursement

figures,

limited

Though

the original bill

[13] . Department of Health officials

accompanying

to

such

data

required we

use

hospital

cost

as

a

proxy.

access

the

fiscal

note

was

an

accurate

estimate

of

actual

confirmed program

4 Data

from

the Census Bureau

indicates

that 23% of Utah

children

(all

ages)

are

costs. The figures used

in

the analysis

include a one-time

insurance, but national data broken down by age

indicates

that

insurance

on public

for

the

youngest

children

tend

to

be much

higher,

45.2%

[14]

2013

Annual

rates Social

cost

of

$4000

and

an

annual

ongoing

appropriation

of

startup

and

Economic

Supplement

Current

Population

Survey,

City,

2013.

Utah

$30,800 1 .

indicates

that 37.5% of

children born

in 2013 were born

Department of Health data

medical

costs

and

cost

avoidance

(benefits)

Calculating

insurance

[15] Bergevin A,

Personal Communication with Kobi Young at

on public

calculating

the

number

of

estimated screenings

screenings

each

required

Utah

Department

of

Health,

City,

2014.

All

of

these

data

points

represent

the

coverage

rates

and do not

account

for

changes

caused

by

the Affordable

historical

as

well

as

the

rate

of

positive

that

would

be

year

Care

Act

(ACA)

and

potential

Medicaid estimates

expansion

in

the

state.

Even

without

for

further

evaluation

and

treatment.

For

infants

who

referred

expansion,

the

state

that

using

current

eligibility

guidelines,

Medicaid 63.5–80%

positive

but

who

were

found

to

have

normal

hearing

tested

of

children

are

eligible

for

CHIP

or

Medicaid;

if

larger

numbers

of

taking advantage of

their eligibility

from ever

the ACA,

then state public

individuals start

1 In

the

second

year

additional

funding was

given,

but

administrators

note

this and

for

infants

could

reach

higher

rates

than

before.

insurance

5 Use

to

be used

exclusively

for

the

educational

component

of

the

law

of

antiviral medications

to

treat

hearing

loss

in

otherwise

asymptomatic

funding was

thus

excluded

from

our

analysis, which

evaluates

the

screening

component

is still experimental. We assume a majority of patients will

choose in Utah.

to

was

CMV patients

alone.

undergo

antivirals

because

preliminary

data

shows

that

to

be

the

case

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